CHF and rapid A-Fib

[DieselBolus17]

Say you are dispatched to the home of a 80 y/o male, woke from his sleep severely short of breath. Long hx of CHF and A-fib. Monitor shows a room air sat of 88%, and a rapid a-fib at a rate of ~180. How would you treat this patient? My thinking is...if treated with Cardizem to control rate, wouldn't the cardizem impair the weakened heart due to hx of chf to an extent by weakening contractions? If treated with sync. cardioversion, the possibility of throwing a clot is definetly there due to long hx a fib? How would you treat this Pt. and why? (I'm in school, cut me some slack xD)



Also, as an off topic question: Say you have a Pt. that bumped his head against the ground due to ground level fall, has a seizure that lasts about 20-30 secs and has LOC for about 2 minutes or so after. GCS 15 afterwards. Would a severe head injury be likely? Or are seizures common with minor TBI? I guess my question is would this Pt. be taken to a trauma center for the possibility of a head injury, or would a local hospital be able to handle, provided all other v/s are stable. Thanks in advance.

 

[Aprz]

I haven't been present to see cardizem pushed or discussed it. I've seen many cardizem drips, and usually the heart rate is still on the upper end of normal or still tachycardic (at 5-10 mg/hr). I think logically the primary problem is the rate being too fast, and it will probably not decrease the chronotropy and inotropy too much.

I would transfer the patient that bumped their head to a trauma center. Positive loss of consciousness and seizure are not good signs. That's what I have been taught, but not really sure what that would indicate. Perhaps a subdural hematoma? I think I recall reading that many people with subdural hematomas will have loss of conscious for a very short time after an incident, but then return to normal. They'll slowly have a bleed over several hours to days before they start showing signs and symptoms of a bleed.

Good questions since cardizem isn't within the scope of practice for paramedics in my area, and I have never really considered why positive loss of consciousness and seizure would be bad other than I have been told that it probably means they have a bleed. I don't think it would provoke a seizure unless there was some trauma to the brain literally.

 

[Brandon O]

Fell then seized or seized then fell?

 

[DieselBolus17]

Fell then seized or seized then fell?

fell, then seized. ground level fall. vital signs within normal limits, pupils equal and reactive, gcs 15 after regaining consciousness.

 

[Brandon O]

Okay, but do you mean they merely tripped on a brick or something, and there were no prior prodromal symptoms at all? Aura, tonic contractions, dizziness, nads? It's one thing if they didn't start overtly shaking until they were down, but that doesn't mean the seizure didn't start earlier and cause the fall. And is there prior history of seizures?

 

[DieselBolus17]

Wasn't trying to get you guys to over think it lol, trip and fall, bumped head against ground, then had a seizure, no hx of seizures. What im trying to get at is that the bump on the head caused the seizure, now is that common for minor/mild TBI due to the contrecoup/irritation of brain tissue?

 

[teedubbyaw]

I want a whole lot more of an assessment, but just based on that information, lets try CPAP first and see if we can't get his rate down through bringing his sats up.

 

[Brandon O]

Wasn't trying to get you guys to over think it lol, trip and fall, bumped head against ground, then had a seizure, no hx of seizures. What im trying to get at is that the bump on the head caused the seizure, now is that common for minor/mild TBI due to the contrecoup/irritation of brain tissue?

What I'm trying to get at is that it matters. If the seizure was truly after the fall, with no other seizure history or prior signs of seizure, then it was presumably caused by the trauma as you suggested. Seizure is a complication of TBI but a rather significant one, so this would suggest major trauma. I would go to The Big Hospital unless it's quite far.

The seizure preceding/causing the fall is both more common and less concerning; it would be treated like any other fall-and-bonk.

 

[DieselBolus17]

What I'm trying to get at is that it matters. If the seizure was truly after the fall, with no other seizure history or prior signs of seizure, then it was presumably caused by the trauma as you suggested. Seizure is a complication of TBI but a rather significant one, so this would suggest major trauma. I would go to The Big Hospital unless it's quite far.

The seizure preceding/causing the fall is both more common and less concerning; it would be treated like any other fall-and-bonk.

Understood, thanks

 

[Burritomedic1127]

For the Afib pt whats the BP and Lung sounds?

If the pressure is "stable", 0.25mg/kg of diltiazem for the HR. Dilt does have pretty significate hemodynamic effects so if the pressure was above 100 systolic i would try CPAP

If pressure/pt was "unstable", id cardiovert at 200 jolues then try CPAP if HR was controlled and pressure was stable. Hopefully with a long hx of Afib hopefully the pt is on coumadin.

 

[Clare]

It would depend if the AF is the primary problem or if the CHF is the primary problem.

If AF is the main problem and the patient is already well anti-coagulated (i.e. on long term warfarin or similar) then thrombus would not be a problem. It's only patients with entirely new onset AF > 72 hrs. that thrombus is a problem.

If CHF is the main problem them we need to look at the underlying problem causing the CHF - the most common is acute infarction or myocardial ischaemia. Treat as such.

 

[Brandon O]

If AF is the main problem and the patient is already well anti-coagulated (i.e. on long term warfarin or similar) then thrombus would not be a problem. It's only patients with entirely new onset AF > 72 hrs. that thrombus is a problem. .

To clarify, it's a question of whether they're currently anticoagulated or not. Having existing A-fib doesn't confer protection, it just potentially confers anticoagulation.

 

[Carlos Danger]

http://www.aliem.com/beta-blockers-...fibrillation-rate-control-thinking-beyond-ed/

 

[DrankTheKoolaid]

Verapamil has never failed to work each time I've used it on a patient that was stable enough for it. Pre treating with CA on the other hand even when given slow has pucker my arse on occasion though

 

[Rialaigh]

I hate to be this guy but if we are talking about a transport time of less then 20 minutes or so and you can keep him from decompensating with some O2, (pressures stable, etc) then slap some O2 or CPAP on him and get him to the hospital. If I'm 30 minutes plus out then a lot of this scenario management depends on blood pressure. Are we talking 260/140 with full lungs, are we talking 80/40 with mildly wet lungs, and then the patients work of breathing, not his O2 sat.

If we are zeroing in on the heart rate as the problem I could use Cardizem slow IVP, although with this patients age I would be more likely to throw a dose in a 100ml bag and run it in over 10 minutes. If I have concerns about hemodynamic stability cardioversion is an option, I would however strongly consider an Amio drip over 10 minutes for rate control if this patient has a long history of Afib and is indeed on Coumadin or something similar. If hemodynamic stability is an issue I am wondering if the lungs would be full as well or if there is just associated SOB, I would then consider a hefty fluid bolus if the lungs are sounding at least decent.

If the breathing is the problem that we zero in on, and we think its the first problem and causing a heart rate of 180. Then I am guessing his work of breathing is terrible now, hes exhausted, his lungs are full, and if we don't Cpap rapidly then hes getting tubed and never coming off a vent.


As far as cardioverting goes (and I may be terribly wrong with this) but this patient does not seem to have an acute electrical heart issue that would cause this (if he does have an extensive history). He has some underlying problem that is making his long standing Afib worse. I would not be a fan of cardioverting because of that, his history, his age, etc...I just don't think that's a good fix in this situation at all.



There are many things you can do for this patient. Cardizem is a good medication when used properly, in the right dose, with the right indication, and with the right patient. I would strongly urge you to consider what your transport options are, underlying cause, and make a risk/benefit decision based on what is best for the patient. If you think reasonably (95%+) that you can put a non rebreather on this guy, drive 10 minutes to a hospital, and dump him with no decompensation then I would urge you think about all the things you can NOT do for this patient to improve his outcome.

 

[TomB]

"I want a whole lot more of an assessment, but just based on that information, lets try CPAP first and see if we can't get his rate down through bringing his sats up."

Agree 100%. Don't forget the nitroglycerin!

 

[wanderingmedic]

Are we talking 260/140 with full lungs, are we talking 80/40 with mildly wet lungs, and then the patients work of breathing, not his O2 sat.

This. If the pt has CHF, they may very well have a prior hx of A-fib. However, if the A-fib is new onset....then I would be thinking very hard about cardioversion. If they are already on blood thinners (like warfarin), then you have a lower risk of throwing a clot. However if they are on warfarin, it is probable they were prescribed warfarin for their A-fib. If the A-fib is preexistent then there is a chance it is not the cause of the current dyspnea. The high HR may be a response to another etiology, and not a result of A-fib. This is where a good history and med list is helpful.

A chronic CHF pt will probably run a little low in terms of SPO2 anyways, so 88% may not be to far off from their normal. A NRB wouldn't hurt here, and the pt may find some slight relief. Also don't get tunnel vision. The difficulty breathing could be unrelated to CHF or A-fib - think PE, pneumonia, bronchitis, etc. What does a 12-lead show, and how wet are the lungs? Is the pt coughing up pink frothy septum?

 

[MrJones]

...Is the pt coughing up pink frothy septum?

Damn auto-correct.